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While public health officials scramble to keep up with more than 100 measles cases across 14 states now, some vaccine researchers have been calling for a solution to this problem before it arrived. Gregory Poland, editor in chief of the scientific journal Vaccine, founded and heads the Vaccine Research Group at in Rochester, Minn. A major focus of his team's research is learning how genetics play a role in how individuals respond to vaccines and whether they experience any adverse events – and measles is among the main diseases the center studies.

Poland said he became seriously interested in measles and the vaccine during the 1989-91 outbreak, which killed 123 people and hospitalized thousands. But anywhere from 20 to 40 percent of the cases occurred in people who had received one or two measles vaccines, leading to the recommendation of a second dose on the childhood schedule. So Poland wrote about what seemed a counterintuitive idea: in very highly immunized populations, most measles cases were going to occur in those who were immunized – but not because the vaccine is worse than others on the CDC childhood immunization schedule. Rather, it had to do with rates of primary and secondary failure of the vaccine combined with how incredibly contagious the disease is, infecting 90 percent of susceptible individuals and remaining airborne for up to two hours. With primary failure, a person's immune system doesn't respond to the vaccine and make the necessary antibodies. In secondary failure, the body makes the antibodies, but they fade over time. (I wrote about both in detail here.)

In the avalanche of media coverage about the current outbreak, Poland's comments have frequently shown up but often out of context. So I interviewed Poland to learn what he thinks about the current measles vaccine, the ongoing outbreak, those who refuse to vaccinate and the future.

Tell me about the measles vaccine.

On the one hand, we have the most transmissible disease known in humans, and on the other hand we have an excellent vaccine – which is not a perfect vaccine – and we don't induce immunity in somewhere between 2 to 5 percent of the people who receive it. When everybody is vaccinated, the only cases you'll see are those in cases who are immunized, though you'll see very few cases compared to a population that doesn't have high levels of herd immunity. This is counterintuitive, and people misunderstand it. For any other disease, that's an out-of-the-ballpark, grand slam vaccine, but with measles, it's not because of the high transmissibility and the high level of herd immunity needed.

What are some of the challenges of preventing measles?

While we eradicated smallpox, measles was next on the list, and we've missed that deadline five times now. Can we control and eliminate measles? Sure, we have. It was eliminated in 2000 in the U.S., so the only cases that occurred were imported. But as we creep toward that goal of eradicating measles, we may need an even better vaccine than what we have. I'm not saying the vaccine isn't any good. In fact, it's an excellent vaccine. But in the very unique niche of such a highly transmissible disease, and having a couple percent who don't respond, and then a growing subpopulation who cannot get the vaccine, we may need an even better one. More people survive [disease such as cancer] now, but live on anti-rejection immunosuppressants the rest of their lives. That was the reason for calling for an even better measles vaccine, one that perhaps would not be a live viral vaccine, where there wouldn't be any contraindication for the immunocompromised. We make it more immunogenic, so maybe we don't have that 2 to 5 percent who don't respond, and we make it cheap and easy to administer worldwide.

Measles-caused pneumonia. Image in the public domain.

Is there any other vaccine as effective as the measles vaccine?

Probably the one that would most hit that would be tetanus vaccine [which prevents a bacterial infection], but in terms of a viral vaccine, maybe smallpox. Probably no other routinely used viral vaccine is as effective as the measles vaccine.

Is measles likely to return to the U.S. for good?

Every time you add another sub population of people who are not protected, you grow the pool of the susceptibles, and if you have a large enough pool spread across enough areas, you can reestablish measles. If the only susceptibles were those in whom the vaccine failed, you would only have very small outbreaks of one or two or three people spread across time. The reason this is a big issue is that we do have this undercurrent of vaccine-hesitant and vaccine-refusing patients. And we do have failure.

The point is, to say the obvious, that we have an excellent vaccine, but we find ourselves in a unique situation right now. We've eliminated measles through indigenous transmission, but we have a small failure rate of the vaccine, and a growing sub population of people who won't get the vaccine. The point in my editorial was that we might be able to solve all those problems by developing an even better vaccine. But that's what people misunderstand. Both sides hear what they want to hear, and when I'm writing to scientific community, I think some of the nuances could be misinterpreted by laypeople or by people with an agenda. They think, "Hey, here's somebody who's saying it's not good vaccine" because that's what they want to hear.

Tell me your thoughts about those who choose not to get their children vaccinated.

One of the things I take as valid health criticism, as my daughter, a psychologist, has pointed out, is that we in the medical profession have not done a good job of discussing or explaining this to our patients. She developed an idea that people have different preferred cognitive styles and decision-making behaviors and that what we need to do is not stick only to the highly analytic cognitive style of a physician – all about the facts and data and numbers – but to determine the cognitive style of the patient in the front of us. Then it's incumbent upon us to best meet the cognitive styles of the patient. I think we have erred in not doing that.

I don't think my patients who reject vaccines are nuts. They have come to conclusion – I believe their conclusion is in error – but they have come to a conclusion that the vaccine is not good. I've yet to meet a parent who doesn't want to do the very best for their child, including vaccines. What I try to do now is that I then try to determine the style they use to make decisions under uncertainty, and that often means I have to establish a rapport or relationship with that patient before they will consider getting a vaccine. Or they may decide never to, but I often view my role as a physician as a patient advisor, and I try to give them the best information we know and have. If they make a choice that I think is adverse to that, I will let them know.

How has the measles vaccine affected cases of the disease, and the complications and deaths that can come with the disease?

The measles vaccine has dramatically decreased cases because of the lower number that occur. The risk of taking the vaccine itself would be, if it was administered properly, maybe about a one in million chance of anaphylaxis. Otherwise there really aren't life-threatening issues or complications associated with the vaccine. On the contrary side, should you develop measles, 1 in 1,000 develop encephalitis. During the outbreak in 1989-91, 3 out of 1000 kids died. It's not for everybody a benign disease. For many children, it will be benign, but you can't predict that, nor can you predict who they are going to expose, who may have more serious complications.

The way I often conclude my conversation with patients is that there are no risk-free decisions. The observed risk of autism due to MMR is zero. The risk of anaphylaxis is 1 in a million. The risk of any other life-threatening illness has got to be so small, maybe one in 10 million, that we can't detect it. Now let's look at the measles. If we're wise, we always the lower risk with the higher benefit, because that's what a rational person would do, enhancing their benefits while minimizing their risks.

During residency, I was chosen to go in and tell a mother that her baby was dead from pertussis. Back then, the fear was about SIDS and DPT, and she had elected not to immunize her baby. It was such a bad case that this woman's life was tragically altered by the death of her baby daughter, and for as long as this mother lives, she regrets every day that she did not immunize her child.

People get to choose, but there are consequences to those choices. Yes, parents are allowed currently to make that choice not to vaccinate, but with a disease this transmissible, and the complications that can occur, you're also choosing for other people because your child is going to expose somebody, perhaps before you even know your child is sick. And what's going to happen to those people? Like any rational society, we depend on the idea that people will make good decisions and have good will. But I've spent my career talking about this stuff, and I've found actually THE most contagious disease is fear. But to be afraid is to be ignorant in a case like this.